Application worksheet

Name of organisation:*

Contact person:*

Postal address:*

Telephone:*

Email:*

Do you wish to speak in support of your application:*

Name:*

Phone:*

Name:*

Phone:*

Are you a club or a school?*

1. How many members belong to your club/school?*

2. How many participants aged between 5 & 18 will this travel subsidy benefit?*

3. How many participants are aged between 5-11 yrs.*

4. How many participants are aged between 12-18 yrs.*

5. Please detail how many applicants are female*

6. Please detail how many applicants are male*

7. Does your application involve a partnership with a local school / club?*

8. What is this funding going to be used for? A very detailed explanation is required please. How many weeks is the season, how many km’s will be travelled and how often. How many vehicles do you suggest this travel fund will support?*

9. Do you have any disabled individuals who are being supported by this fund?

a. If yes, how many will receive support from the RTF?

10. What percentage of your members live in the vicinity of the local authority you are applying to for the rural travel fund?*

1. Are you registered for GST?*

(If yes please write your GST Number in the space provided)

2. How much money are you applying for?*

Sport NZ Funding $*

Other funders $*

Your contribution $*

Total: $*

3. If you have applied for funding from other organisations, please supply details - refer to Table 1 below.

Table 1

Organisation - (including other councils)

Amount requested ($)

Results date (if known)

4. Do you have endorsement from your local affiliated club/school for this application for funding? (this is only relevant if the group applying is the regional body).*

(briefly explain and attach evidence of this)

We hereby declare that the information supplied here on behalf of our organisation is correct?*

We consent to authority collecting the personal contact details and information provided in this application, retaining and using these details and disclosing them to Sport NZ for the purpose of review of the rural travel fund. This consent is given in accordance with the Privacy Act 1993.*

1. Name:*

Position in organisation/title:*

Signature:*

Date:*

2. Name:*

Position in organisation/title:*

Signature:*

Date:*